JOURNAL OF APPLIED CLINICAL MEDICAL PHYSICS, VOLUME 16, NUMBER 3, 2015
AAPM Medical Physics Practice Guideline 3.a: Levels of
supervision for medical physicists in clinical training
Task Group Authors: J. Anthony Seibert, Chair, Jessica B. Clements,
Per H. Halvorsen, Michael G. Herman, Melissa C. Martin, Jatinder Palta,
Douglas E. Pfeiffer, Robert J. Pizzutiello Jr., Beth A. Schueler, S. Jeff
Shepard, Lynne A. Fairobent, AAPM Staff
The American Association of Physicists in Medicine (AAPM) is a nonprofit
professional society whose primary purposes are to advance the science, education and professional practice of medical physics. The AAPM has more than
8,000 members and is the principal organization of medical physicists in the
United States.
The AAPM will periodically define new practice guidelines for medical physics
practice to help advance the science of medical physics and to improve the quality of service to patients throughout the United States. Existing medical physics
practice guidelines will be reviewed for the purpose of revision or renewal, as
appropriate, on their fifth anniversary or sooner.
Each medical physics practice guideline represents a policy statement by the
AAPM, has undergone a thorough consensus process in which it has been subjected to extensive review, and requires the approval of the Professional Council.
The medical physics practice guidelines recognize that the safe and effective
use of diagnostic and therapeutic radiology requires specific training, skills, and
techniques, as described in each document. Reproduction or modification of
the published practice guidelines and technical standards by those entities not
providing these services is not authorized.
The following terms are used in the AAPM practice guidelines:
•Must and Must Not: Used to indicate that adherence to the recommendation
is considered necessary to conform to this practice guideline.
• Should and Should Not: Used to indicate a prudent practice to which exceptions may occasionally be made in appropriate circumstances.
Approved August 8, 2014
1.Introduction
The purpose of this practice guideline is to address the levels of supervision necessary for the
clinical training of medical physics students, residents, and medical physicists-in-training.
During the training of these individuals, it is often necessary or desirable for them to perform
functions generally performed by Qualified Medical Physicists (QMPs). In such circumstances,
the individuals performing these functions must be appropriately supervised and the scope of
the functions to be performed must be carefully defined. This document does not address the
use of medical physicist assistants or medical physics extenders (i.e., positions not intended to
provide a path to becoming a QMP).
It is the responsibility of all individuals to be familiar with federal and state regulations
regarding supervision that may take precedence over the recommendations.
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2. Definitions
a. Competency — The demonstrated ability to perform the medical physics-related task or
function independently.
b. Cosigning or Cosignature — The process of obtaining a second signature or the formal
process by which a report produced by a supervised individual is finalized by the supervising QMP. The QMP retains full responsibility for the trainee’s work.
c. Formal Work Product — A deliverable or outcome that must be produced as part of the
clinical work to complete a project and achieve its objectives.
d. Medical Physicist-in-Training — An individual who meets the requirements of certification, and is currently in the preparation to complete board certification in one or more
of the subfields of medical physics.
e. Medical Physics Student — An individual enrolled in a master’s or doctoral degreegranting program from an approved institution (e.g., program accredited by one of the
organizations recognized by the Council on Higher Education Accreditation, or its successors), in medical physics, physics, or another relevant physical science or engineering
discipline.
f. Medical Physics Resident — An individual enrolled in a structured training program
designed to educate and train to a level of competency sufficient to practice medical physics independently. This individual must have obtained a master’s or doctoral degree in
medical physics, physics, or another relevant physical science or engineering discipline.
An individual enrolled in a Doctorate of Medical Physics (DMP) program also meets this
definition of Medical Physics Resident while completing their clinical rotation requirements of the DMP program.
g. Qualified Medical Physicist — As defined by AAPM Professional Policy 1.(1)
h. Supervision: Oversight of and acceptance of responsibility by the QMP for the medical
physics-related work performed by a Trainee or Medical Physics Student:
i. General Supervision — The procedure is performed under a QMP’s overall direction and control, but the QMP’s presence is not required during the performance of
the procedure. Under General Supervision, the training of the personnel who actually
perform the procedure, and the maintenance of the necessary equipment and supplies,
are the continuing responsibility of the QMP.
ii. Direct Supervision — A QMP must exercise General Supervision and be present in
the facility and immediately available to furnish assistance and direction throughout
the performance of the procedure. It does not mean that the QMP must be present in
the room when the procedure is being performed.
iii. Personal Supervision — A QMP must exercise General Supervision and be present
in the room during the performance of the procedure.(2)
i. Supervisor — A QMP who oversees the medical physics-related work of a supervised
individual in a clinical environment.
j. Supervised Individual — A medical physics student, resident or medical physicist-intraining performing medical physics-related tasks under the direction of a QMP.
k. Trainee — The term “trainee” is used to include medical physics residents and medical
physicists-in-training.
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32 AAPM: Medical Physics Practice Guidelines32
3.Roles of the Medical Physics Student, Medical Physics Resident, or Medical
Physicist-in-Training
a. Medical Physics Student
Medical physics students should be capable of performing basic medical physics tasks
with appropriate training, such as the collection of X-ray generator calibration for­
diagnostic / orthovoltage systems or linear accelerator depth dose data. The medical
physics student is not expected to analyze or make decisions regarding the data, but may
make comments or recommendations to the supervising QMP, and should be involved in
the discussion of the data to further their education. If the medical physics student works
on clinical medical physics tasks, it must be under the personal or direct supervision of
a QMP, as deemed appropriate by the QMP.
b. Medical Physics Resident
Medical physics residents are expected to grow in the degree of responsibility and independence of clinical practice. Early in residency, the resident should have responsibilities
similar to medical physics students. Personal supervision should be provided for the initial
performance of tasks within the medical physics scope of practice.(3) The resident, with
experience and training, should progress to analysis of the data and performance of some
functions under direct supervision. Late in the residency, the resident should be able to
function largely as a QMP, with the supervisor balancing the transition from supervision
toward independence of the resident during the residency program.
c. Medical Physicist-in-Training
Medical physicists-in-training are expected to grow in the degree of responsibility and
independence of clinical practice. With increasing experience, medical physicists-intraining should be able to function largely as a QMP, with the supervisor balancing the
transition from supervision toward independence.
4. The Responsibilities of the Supervisor
Supervision is a responsibility that must not be undertaken lightly. The supervisor must assume
professional responsibility for the medical physics-related work done by the supervised individual. Should an untoward event occur, the professional reputation of the supervisor is at risk
as if the supervisor had personally caused the incident.
Supervision of a trainee requires regular, high-quality interactions between the supervisor
and the trainee during which medical physics is practiced by the trainee under the guidance of
the supervisor. As the trainee grows in professional maturity, it is appropriate for the supervisor to allow the trainee greater responsibility and autonomy, with the understanding that the
supervisor must still review and cosign all formal work products of the trainee. Formal work
products could include reports of machine calibrations, shielding designs, treatment plan
reviews, patient-specific quality assurance measurements, treatment record reviews, and equipment evaluations. By cosigning, the supervisor takes full professional responsibility for it as
if it were the supervisor’s own work. For “low-level” work products as identified by the QMP
supervisor, a supervised individual who has demonstrated competency through a formal work
product may be able to independently sign off (the work product must describe the experience
gained through personal, direct, and general supervision of the supervising QMP). Nevertheless,
the supervising QMP retains full responsibility for the supervised individual’s work for that
specific work product, and all other work not similarly documented must be cosigned.
The supervisor must have a professional relationship with the supervised individual that
allows the supervisor to observe the work of the supervised individual and to correct that work
if necessary. The supervisor should not commit to the supervisory relationship if:
a. The supervised individual and the supervisor work for different employers without a
formal agreement outlining the supervisory relationship.
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33 AAPM: Medical Physics Practice Guidelines33
b. The supervisor is unable to consistently provide the appropriate level of supervision.
c. The supervisor has not committed to assuming full professional responsibility for the
supervised individual’s work.
d. Except under documented extenuating circumstances (e.g., illness or job transition), or
episodic training sessions, a supervisor must not supervise for the clinical training of
medical physics:
i. more than two medical physics trainees at one time; and
ii. more than two medical physics students at one time; and
iii.more than three full-time equivalents per supervisor. Supervised individuals
who are part-time in their clinical medical training are counted as their fractional
FTE-equivalent. For example, a medical physics student may only have 0.25 FTE
in the clinic.
During a supervisor’s absence, the supervisor is responsible for delegating the required
supervision to the QMP providing coverage for the supervisor. There must be a clear description
of what tasks may be performed independently by the supervised individual and under what
circumstances a delegated QMP must cover the supervisory responsibility.
During a supervisor’s absence from work, the supervised individual must only be allowed to
perform tasks for which that individual has demonstrated and documented formal competency
to work independently. Documentation of the supervised individual must be readily accessible
in order to verify the ability to work independently. The exception is when the supervisor has
a coverage arrangement with a colleague QMP during vacation time or other absence and that
a coverage agreement specifically includes supervision of the supervised individual.
5. The Responsibilities of the Supervised Individual
The supervised individual must not perform clinical medical physics-related tasks without
appropriate supervision or documented competency by the QMP supervisor.
For supervised individuals in states with professional licensure of medical physicists:
Currently, states that license medical physicists may require an individual working toward
becoming a QMP to have a temporary or limited scope license to practice. If a supervised individual holds a temporary license in more than one subfield of medical physics, the supervisor
must be fully licensed in all of the subfields the supervised individual is training toward (or in
which the supervised individual holds a temporary license); otherwise, the supervised individual
must secure more than one supervisor. However, the individual state mandates for supervision
must be followed, as requirements may not be consistent in all states. It is the responsibility of
the supervised individual to ensure that his or her supervisor(s) are licensed in the subfield at
the time of the application for a temporary license.
6. A General Progression of Supervision for Trainees
There must be a progression from personal to general supervision for trainees. A supervision
plan must be available and acknowledged by the trainee and the supervisor. Competency performance reviews should be completed and documented for each activity.
a. Supervision Plan
A supervision plan must be formally adopted and document well-defined progression of
levels of responsibility for trainees.
As an example, a plan consisting of the following would meet the intent of this document:
• Personal supervision for the first six months,
• Direct supervision for the remainder of the first year, and
• General supervision in the second year.
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34 AAPM: Medical Physics Practice Guidelines34
Note that the supervisor is not relieved of the responsibility to review and cosign reports,
and retains full responsibility for their content.
b. Considerations in Developing a Supervision Plan
Prior to determining the assignment of work, the facility must have a procedure consistent
with the cosignature procedure for determining the conditions under which a supervised
individual can practice.
Care must be taken to provide sufficient supervision to all supervised individuals. It is
essential that the QMP determine whether a supervised individual may visit a facility alone
for a specific activity. The QMP must determine whether the QMP should also personally
participate in the initial visit (or more as required) to a facility to address unanticipated
issues. A supervised individual must not be sent alone to perform a procedure that is not in
the scope of practice for the role of the supervised individual, or for which the supervised
individual has not demonstrated formal competency.
It is also essential that the QMP determine at what level a supervised individual may
proceed from personal supervision to direct supervision and from direct supervision to
general supervision. This may be task-dependent, with higher-level functions or critical
patient-care functions requiring more training and experience to be performed under
personal or direct supervision than low-level functions. Examples of such tasks are
measurements performed on clinical teletherapy or imaging equipment to determine the
output or beam characteristics. The progress plan with milestones to be achieved by the
trainee should be documented.
7. Medical Physics Residency Programs
The Residency Program Director must be a QMP and have at least 5 years of full-time experience beyond residency.(4) All faculty members of a medical physics residency program should
be fully qualified (including being licensed if practicing in a state with a medical physics
licensure law) in the clinical activities that they supervise. The Residency Program Director
may delegate day-to-day supervision of residents:
• to his or her colleagues on the faculty who are QMPs, or
• to other qualified faculty or staff members only if:
° a QMP in the appropriate subfield of medical physics cosigns each item of work produced by the resident; and
° the formal supervisor shares with the delegate the authority to observe and correct the
work of the resident.
The Residency Program Director exercises General Supervision over all residents in the
program. The Residency Program Director delegates responsibility for supervision to faculty
members of the residency program by assignment of residents for a task or time period. Faculty
members who have responsibility for supervision of a resident may further delegate authority
for supervision to other faculty members who are QMPs for the tasks to be performed by the
resident, or to faculty or staff members who are themselves medical physicists-in-training and
are appropriately supervised by a QMP.
It is reasonable for one faculty member to be the formal supervisor of all of the residents,
even more than two at a time, and to delegate day-to-day supervision to other qualified faculty
members. Supervision cannot be delegated from a QMP to a resident; however, it is entirely
appropriate for a more experienced resident to assist in the training of another resident. A QMP
must supervise the training of one resident by another, and must cosign the joint work product
of the two residents, who must also sign as residents. The supervising QMP is still ultimately
responsible for the work of both residents.
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8.Recommendations
Clinical practice environments must balance the need for competent staff with the need to train
new professionals and provide services in a safe, yet cost-effective, manner. The guidelines
presented provide a framework for the appropriate supervision and scope of responsibilities
for medical physics students and residents, and medical physicists-in-training.
Specifically:
• The supervisor must assume professional responsibility for the medical physics-related
work done by the supervised individual.
• A supervision plan must be formally adopted and document well-defined progression of
levels of responsibility for trainees.
• Except under documented extenuating circumstances (e.g., illness or job transition), a
supervisor must not supervise:
° more than two medical physics trainees at one time
° more than two medical physics students
ACKNOWLEDGMENTS
This guideline was developed by the Medical Physics Practice Guideline Task Group-243 of
the Professional Council of the AAPM.
TG-243 Members:
J. Anthony Seibert, Chair, PhD, FAAPM, FACR, FSIIM
Jessica B. Clements, MS
Per H. Halvorsen, MS, FAAPM, FACR
Michael G. Herman, Ph.D., FAAPM, FACMP
Melissa C. Martin, MS, FAAPM, FACR, FACMP
Jatinder Palta, Ph.D., FAAPM, FACR, FASTRO, FACMP
Douglas E. Pfeiffer, MS, FAAPM, FACR
Robert J. Pizzutiello, Jr. MS, FAAPM, FACR, FACMP
Beth A. Schueler, Ph.D., FAAPM, FACR
S. Jeff Shepard, MS, FAAPM
Lynne A. Fairobent, AAPM Staff
AAPM Subcommittee on Practice Guidelines — AAPM Committee responsible for
sponsoring the draft document through the process:
Russell Tarver, MS, Chair
Maria F. Chan, PhD, Vice-Chair Therapy
Jessica B. Clements, MS
Dianna D. Cody, PhD, FAAPM,
Jonas D. Fontenot, PhD
Arthur J. Olch, PhD, FAAPM
Joann I. Prisciandaro, PhD, FAAPM
J. Anthony Seibert, PhD, FAAPM, FACR, FSIIM
S. Jeff Shepard, MS, FAAPM, Vice- Chair Imaging
Jennifer B. Smilowitz, PhD
Gerald A. White Jr., MS, FAAPM, FACR
Lynne A. Fairobent, AAPM Staff
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36 AAPM: Medical Physics Practice Guidelines36
REFERENCES
1. AAPM Professional Policy 1. Definition of a Qualified Medical Physicist. Available from: http://www.aapm.org/
org/policies/details.asp?id=316&type=PP
2. AAPM Professional Policy 18. Statement on the Description of Involvement of Medical Physicists in Clinical
Procedures. Available from: http://www.aapm.org/org/policies/details.asp?id=338&type=PP.
3. AAPM Professional Policy 17. Scope of Practice of Clinical Medical Physics. Available from: http://www.aapm.
org/org/policies/details.asp?id=317&type=PP
4.AAPM. Essentials and Guidelines for Clinical Medical Physics Residency Training Programs. AAPM Report
No. 249. Report of the Work Group on Periodic Review of Medical Physics Residency Training. College Park,
MD: AAPM; 2013. Available from: http://www.aapm.org/pubs/reports/RPT_249.pdf
Journal of Applied Clinical Medical Physics, Vol. 16, No. 3, 2015